Shattering boundaries: SA doctor who saved Siya Kolisi’s World Cup dream – Dr Willem van der Merwe

Siya Kolisi, the captain of the Springbok rugby team, believed his World Cup dreams were shattered when he injured his cruciate ligament six months before the Rugby World Cup in France. It was his teammates Pieter-Steph du Toit and Handré Pollard who suggested consulting Dr Willem van der Merwe, a Cape Town orthopaedic surgeon and former Free State all-rounder cricketer. Rachel Kolisi appealed to her social media supporters to pray for the Bok captain, hoping for a miracle. After 119 days led his team onto the Millennium pitch in Cardiff in April 2022, marking a recovery of less than 4 months—significantly shorter than the typical 6-9 months athletes endure. In an interview with BizNews, Dr. van der Merwe attributed Kolisi’s recovery more to the captain’s mindset than medical procedures, though he acknowledged making slight adjustments to the surgery to ensure graft protection. Dr. van der Merwe emphasised the significance of the signals doctors convey to patients, revealing that he advised Kolisi against using crutches and encouraged him to cycle, despite objections from the physio who deemed it too early. The response from peers was predominantly negative, with a French orthopaedic surgeon even berating him for jeopardising Kolisi’s future. According to Dr. van der Merwe, athletes like Kolisi and others, including Chad le Clos, possess a unique presence and confidence. When faced with adversity, they believe in themselves, a trait he regards as truly special. – Linda van Tilburg

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Relevant timestamps from the interview

00:08 – Introductions
00:49 – Dr Willem van der Merwe on Siya’s recovery journey and how it started
02:33 – Injuries of Siya’s nature usually take 9 months to recover
05:19 – On what he does that’s a bit different
06:05 – The negative reaction surrounding the recovery plan
08:49 – On trying to do things differently
09:50 – His support team
10:35 – Dr Willem van der Merwe’s background
13:03 – Siya’s belief
15:41 – South African doctors possess this unique mindset that encourages innovative thinking
16:43 – The uniqueness of Rassie Erasmus
17:50 – The weight of Expectation
19:17 – Conclusions

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Edited excerpts from the interview

Dr van der Merwe has used similar technique on other Boks and SA sportspeople

I played a little bit of sport myself, and I remember certain matches are really important, and I remember how you can get there and the things that can happen. So when Siya came to see me, he was asked by Handré Pollard and Pieter-Steph du Toit to come and see me because I’d done something similar to them.

Pieter-Steph’s operation was in 2015, before the World Cup. He got injured four months before that, and we had to get him fit, and we did that successfully. Handré Pollard was four months before the Lions Tour, and we got him back. So, they said, well, if you want to play, go and see Dr. van der Merwe. I must say, when he came to see me, he was on crutches, and I think there was one Argentinian and an All-Black that tore their ACLs in the same week, and they were out. They were gone. It was over.

So, I said, we have done it before; we have got some different techniques. I cannot promise you, but we can have a go, but we won’t put your health at risk, and your long-term career is more important. Now it’s a good story, everything went out fine, and everything worked out well.

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How a hatred of dogma led to trying new techniques for sports injuries

Siya snapped his ACL completely. I think the average recovery period is six months to nine months, but as doctors, the big thing for us is we don’t want re-injury, but we changed the surgery a little bit.

I think I spent my whole career hating dogma. Dr. Freddy Fu was my mentor. He was from Pittsburgh in the US and he always told me, ‘Listen, there are better ways. You must find a better way to do this.’ He passed away last year—a truly amazing man. When I looked at the literature, the six-month recovery wasn’t really based on science. I think the biggest problem we have is that the athlete doesn’t do anything for six months, and he doesn’t believe in his knee and I think that’s a big problem. But, we did change the surgery a little bit. We made sure that the graft was protected.

We started loading them early, but Siya wasn’t the first one, and we followed them up, and we saw that they actually handled it very well. So, when Siya came to see me, I said, ‘Okay, we’ll do the surgery.’ I think the one thing we did a little bit differently is the athlete himself has to believe that this is fine. After the surgery, I said to Siya, ‘Hey, it wasn’t so bad, you know. It wasn’t a bad injury, although it was, and we didn’t have to repair the whole ACL, but we had to repair it.’

I think the problem with athletes is you can’t tell them, ‘Listen, this is a bad injury. It’s going to take you nine months, your chances of re-injuring it are 30%, your knee is never going to be the same, you’re going to get early osteoarthritis, but be positive.’ You’re not going to be positive. So, I think the signals that we gave them, and I said to him from the start, ‘Listen, your knee is strong now. You don’t need any crutches. You never had crutches.’ I have a video of him walking around. I said, ‘You don’t need crutches; you’re fine.’

I said, ‘Siya start cycling’, and his physio said no, it’s way too early; he hasn’t got all the range of motion. As they walked away, I said, ‘Siya, just between you and me, get on the bike,’ and he got on the bike, and sent me a video.

So, I think a lot of it is not based on true science. He never went to the gym. I said to him, ‘Get back on the field, start throwing the ball around, feel how your knee feels.’ As soon as he felt that his knee was stable and he trusted it, it’s amazing the recovery. So, it’s more to do with him than me.

Using different techniques for knee construction

We use the same graft, we use a hamstring tendon. There are different grafts, but we create sockets in the bone that we put the graft in. So I don’t use the socket in the femur. To get it anatomically, we have to put it at an angle, and I think that angle when you move your knee, that’s what causes that so-called killer corner. I think that’s what causes the problem.

We found a way to avoid that so that the ligament doesn’t have these bends that it has to do, and we saw that it heals better.

Many hoped he would fail

The reaction was very negative. But I looked at the literature, nobody’s ever torn their ACL in the first four months after reconstruction. It’s supposed to be very strong now. So, I’m not sure why this long delay is. I think it’s just passed down from mentor to mentor.

But they all said, no, I’m crazy, and I’m putting him at risk. A good friend of mine from France, a very good surgeon, phoned me. Siya is going to Racing 92, his next club in Paris, and he’s their orthopaedic surgeon. He phoned me and said, “What is the team doing? He wants to bring Kolisi back in three months; I’m sure you all do not agree with this, that they want to bring him back in three months.” And I said, “No, I actually think he’s fine. We looked at him and he’s fine.”

He said, “You are jeopardising his future.” But I think he’s doing better and I think we’ve used the same technique in 18, 19-year-old kids too, which is our real problem. They work well. I think it’s something. I’ve presented it in Japan first and I’ve presented it somewhere else and people just think I’ve done the normal thing and I’m just putting them back on the field early and see how it goes, but it’s not that. But we’ll get there. They say new ideas take about three years to get into the mainstream in orthopaedics.

People are questioning my techniques and I think correctly so. I think if you do one or two and it works, people shouldn’t just change the next day. I think we should study it further and give some more evidence and write some papers, but we’re getting some collaboration overseas. This is something new. We don’t want to put anybody at risk, but hopefully, in two years, it will be more acceptable and done by more people.

I had a professor who says when you have a new idea, there are always three steps. He says the first time you do it, they tell you that this is crazy. What are you doing? Don’t do this. He says and then when it sort of works out they’ll say, “Hmm, interesting, but you have to show the science, and once it works and that, they’ll say, “Oh, but we always knew this. This is nothing new.” So I think if you look for big accolades from your partners, it’s never going to come.

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I think my whole life I’ve been trying to do things differently. I had a few other things that we did. We do e-centric training and I think it’s based on science, but I don’t like just looking up stuff that I’ve done for the last 10 years. So a lot of surgeons say, “I’ve done this for 10 years and these are my results,” and a lot of people haven’t changed their techniques in 20 years. For me, that’s not science.

Tim Noakes, also one of my mentors, said to me, “Everything we do today, 50% is wrong. We just don’t know which 50% but I think if you have that mindset, probably half of what we do is wrong, but we have to be careful and do it properly.” But I think my whole life has been breaking down dogma. I have some French in me, I think.

I must acknowledge Neil van der Walt; he’s my partner. We did a lot of this together. He did a fellowship in Australia with some of the best surgeons there. I had to bounce this off him. He was the negative one and I was the positive one and I think that’s good. Whenever I said he would come up with ideas why it shouldn’t work and then once I convinced him, then we could move on. A lot of people were hoping it failed, that’s for sure.

Dr Van der Merwe’s Big Theory: The healing process is controlled by the Brain

I grew up in the old Transvaal and went to Grey College in Bloemfontein, I then studied medicine there and specialised at UCT. But even then, I always wanted to go to Oxford. I always wanted to see different things.

I played a lot of sports, and I think part of it is that the athlete comes first to me. The Irish have a good saying; I don’t want to step on any toes, but the manager and the physio and the trainer, they call them alickadoos. For me, I never really liked the guy. You’re not the guy making the tackle. You’re just sitting on the side. For me, it’s all about the players, and you have to support them.

The day before the Oxford game, you only get Oxford blue if you play against Cambridge. I hurt my knee. I tore my MCL, and I tore it completely. I felt it going open. So I thought, well, I’ve done so much now. I’ll go the next day, and I’ll just run up, and the first scrum, I’ll stay down, come off, and I’ll get my blue. Even the morning when we played, I felt my knee moving, and I mean I’m not gung-ho, and I’m not stupid. I went on the field, and I never felt it. I played the whole game. I never felt it afterwards.

I think my big theory now is what our brain thinks our knees are and I think we can accomplish amazing things if we don’t interfere with this. This technique works in people like Siya Kolisi, Handré Pollard or Pieter-Steph du Toit. I think there’s some evidence now that the brain controls the whole healing process and can shut down the knee if it gets all these negatives. So, I realise that anything is possible, and we should explore it.

The positive mindset of Siya Kolisi who never spoke about the weight of expectations on him

Siya Kolisi is special, very, very much so. I think the one thing about these sportsmen, when they’re in trouble, they know they’re in trouble. The doctor is everything. He knows his knee is gone, and he’s not going to question what I do.

They’ve got this amazing presence. Pollard had it, Peter-Steph du Toit has it, but they’re all very humble and they’re all confident. All of them, when they have an injury, they never blame anybody. They don’t ask, ‘Why me? Why did it happen to me?’ They always say, ‘Okay, what are we gonna do? When can I start training? How do we fix this?’ They’re very, very positive people.”

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Siya never spoke of the weight of expectation of the nation. To me, it sounded like this was the biggest privilege in his life. He never felt that he owned anybody. He said, listen, I’m already blessed. Even if I don’t play this one, I would like to play and he wanted to contribute. All of these guys never feel that anybody owns them or they have to do something. No, he never mentioned that. He just said, let’s try the best we can, and if we can play, we can play. The one thing he said is he won’t play if he’s not 100% fit. He says he’s not gonna play and be 80% because then he’ll let his team down. So I don’t think they feel expectations. They just look at the future. They don’t feel pressure, these guys.

If I speak to them, they have this presence. Handre Pollard had it, Chad le Close and Graeme Smith had it. It’s confidence, it’s not arrogance. They are all very humble. When the chips are down, they believe in themselves. That’s for sure.

South Africa, is a small, little country that doesn’t like being told what to do

South Africans don’t like being told what to do. I have been in America, and you go to a hospital for special surgery. It’s the most famous orthopaedic hospital. The guy that’s in charge, none of the young guys will ever question what the leader does.

If you go to France, the young guys want to prove their professor wrong. So I think we’re quite humble, but we don’t like being told what to do and just take everything for granted. As you know, we don’t like too many rules, and we don’t like the government telling us what to do.

It is the same with Rassie Erasmus…, I think he’s a genius. What he did right was also this mental attitude of the players if you speak to all of them, and he didn’t speak to me, but I think he needed Siya as part of the team. I got the idea that this team is not the same without Siya. They all said to me, listen, don’t get this one wrong. We need Siya back.

A lot of my colleagues said things about Rassie Erasmus too. They didn’t like Rassie. Tell us South Africans how bad we are and what the bad things are that you do. We use that as motivation. That’s the best motivation you can give us.